The Acute Leukemias and Myelodysplasia

Selina M. Luger, M.D. James Mangan MD Marie Gardler CRNP Normal Bone Marrow Has all of the types of cells necessary to make the blood cells needed in the bloodstream and body < 5% blasts in normal bone marrow Cells mature in the bone marrow and then enter the blood and carry out their functions Blood cells

White blood cells

Red blood cells Platelets Red blood cells

RBC • Carry oxygen • Contain hemoglobin – Normal Hemoglobin 12- 16 g/dl • Without rbc’s feel weak, tired White Blood Cells

WBC • important to the immune system • Several different types – granulocytes – lymphocytes – monocytes • 4,000-10,000/ml • Without healthy functioning wbc’s, unable to properly fight infections Platelets

• Help blood clot properly • Prevent excessive bleeding when injured • 140,000-450,000 / ml • If insufficient, excessive bleeding at wound site, spontaneous bleeding Normal blood cells

Lympho- cytes

Lymphoid Granulocyte Leukemia

 19th century European physicians noted a disorder of elevated white blood cells • “leukos”=white, “haima”=blood  Leukemia • Cancer of the bone marrow which is the organ for normal blood cell development • Results in uncontrolled growth of abnormal blood forming cells in the bone marrow which affects the number of normal cells in the blood Leukemia--Epidemiology 35,000 new cases in US/year 90% in adults • 10 times more often in adults than in children Incidence of leukemia has decreased by 1.1% each year since 1995 Myeloid vs. Lymphoid Acute vs. chronic Classification of leukemias

Acute Chronic

Myeloid Acute Myeloid Chronic Myeloid Leukemia Leukemia (AML) (CML) origin

Lymphoid Acute Lymphoblastic Chronic Lymphocytic Leukemia origin Leukemia (ALL) (CLL) Chronic Leukemia Increased number of mature, although abnormal white blood cells In its early stages, many patients without symptoms • Even though there are too many mature cells, early on the disease has no effect on the other blood counts Course variable May be controllable for years, with or without medication Acute Leukemia

Uncontrolled proliferation of a malignant clone of immature hematopoietic cells • 20% bone marrow cells are blasts Transformed cells incapable of normal differentiation Leukemic cells prevent the maturation and differentiation of other bone marrow cells Disease progresses rapidly and is fatal without treatment Myeloid maturation

myeloblast promyelocyte myelocyte metamyelocyte band Neutrophil or granulocyte

MATURATION

Adapted and modified from U Va website PB in AL vs CML vs normal

CML AL normal blasts   promyelocytes  myelocytes  metamyelocytes  bands  neutrophils   

ALL

 Acute leukemia where blasts are lymphoid in origin  3000-5000 new cases per year in US  20% of adult leukemias  75% childhood leukemias • Childhood cancer is leading non-accidental cause of death in children • most common childhood malignancy • Peak age is 4 years old (60% of ALL in children) AML

 Acute leukemia where >20% of the bone marrow cells are non- lymphoid blasts  The most common type of leukemia diagnosed in adults • 80% of adult leukemias • 11,000 cases per year Myelodysplastic syndrome

Myelo= bone marrow, Dysplasia= abnormal appearance Results in the production of too many defective blood cells and not enough normal blood cells First described back in 1913 • Categorized in 1955 • Formal diagnostic criteria established in 1974-75 and updated in 1999 Used to be called preleukemia, but many patients never develop leukemia, but still have problems related to lack of normal blood cells. MDS—Epidemiology

Clonal disorder where the bone marrow is making too many non-functional cells. 55,000-60,000 new cases/year in US (Adults)  Predominantly a disease of the elderly • Median age > 60; • 70% over age 50 • Incidence greater in males 100 • Incidence increases with age 10

1 Rate 0.1 Males Females 0.01 Signs & Symptoms

 Anemia (low red cells) results in fatigue, pallor, shortness of breath, chest pain  Thrombocytopenia (low platelets) results in easy bruisability, gum or nose bleeds  White blood count can be low or high • Neutropenia (low neutrophil count) results in recurrent infections or poor healing • Occasionally patients may present with symptoms related to a high white blood count How is the diagnosis made?

Blood • Sometimes we can see abnormal cells in the blood • Anemia, and low platelet count  Bone marrow tests

Bone marrow in acute leukemia and MDS necessary for diagnosis useful for determining type useful for prognosis Acute leukemias are defined by the presence of > 20% blasts in bone marrow MDS defined by either presence of 5-20% blasts, or funny looking cells Abnormal chromosomes/DNA may be identified in bone marrow cells Chromosomes

 Small bodies in the nucleus of the cell made up of DNA  Instructs cells on how to make copies of themselves and get copied every time a new cell of that type is made  DNA carries information that controls the production of proteins and other molecules essential to cell function

Normally each cell has 22 pairs of chromosomes and 2 additional chromosomes. Normal vs MDS/leukemic stem cells

 Normal stem cells replace themselves as needed and make copies of themselves so to increase production of normal cells as needed and die off when not needed  It is possible for the DNA in stem cells to get damaged over time. – Excessive radiation—e.g. atomic bomb – Chemotherapy, Benzene • Other times DNA is damaged without any clear reason  In MDS/leukemia, a defect occurs in one of the stem cells and all of its copies carry that same defect—these stem cells are not capable of maturing into normal healthy cells • These defective cells make too many copies of themselves and crowd out the normal stem cells • As a result the bone marrow is filled with lots of dysfunctional, abnormal stem cells and few normal stem cells and these cells cannot mature and send healthy mature cells into the blood stream. Leukemia, MDS and chromosomes  We have been able to evaluate the chromosomes of thousands of patients with leukemia and MDS and we have learnt that • certain chromosome abnormalities are associated with specific leukemia types • the chromosomal changes can be important in prognosis This chromosome abnormality is found in leukemia cells of patients with AML and is associated with a better than normal chance of getting into remission and a better chance of staying in remission with our treatments. This chromosome abnormality tells you the patient has M3 AML and needs a specific treatment. Multiple cytogenetic abnormalitites

In patients with more than 3 abnormal chromosomes, hard to keep away with standard treatment, need aggressive treatment to fix the diseased bone marrow Mutational Profiling of the ECOG 1900 Cohort*

Mutational profiling of all genes known to be mutated in AML FLT3 NPM1 IDH DNMT3 TET2, NRAS, MLL,CEBPA, ASXL1

Marked mutational heterogeneity

Prognostic impact of mutations

Novel Prognostic Factors New Techniques & New Data Cytogenetics • Updates in classification from large databases • SNP arrays to detect occult cytogenetic lesions Gene mutations Altered (over-) expression of individuals genes • Gene expression profiling Gene regulation • MicroRNA expression signature • DNA methylation profile Proteomic profiling • Activation (phosphorylation) of signaling pathways  MRD

The Penn experience: mutations in acute myeloid leukemia

FLT3- SF3B1, 3 KRAS, 2 ATM, 1 other, 2 abnormal RUNX1, 4 GNAS, 1 WT1, 3 KIT, 3 PTPN11, 5 variant NPM1, 25 IDH1, 6 FLT3 normal FLT3-ITD , - TET2, 8 18 D83 DNMT3A, 5, 7 14 NRAS, 12 CEBPA, 13 88.5% IDH2, 8

A total of 670 pathogenic Mutations were detected: 270 AML specimens were ~2.8 mutations/ positive case sequenced Of the 15 pts with no mutations, Pathogenic mutations were 10 had abnl karyotype detected in 89% cases Comprehensive Classification VAF Driver Mutations in AML

Metzeler, Klaus H. et al "Spectrum and prognostic relevance of driver gene mutations in acute myeloid leukemia." Blood (2016): blood-2016-01-693879. Web.31 Oct. 2016. Mutations in therapy-related AML. A comutation plot shows nonsynonymous mutations in individual genes, as labeled on the left.

R. Coleman Lindsley et al. Blood 2015;125:1367-1376

©2015 by American Society of Hematology Cytogenetic Abnormality in ALL: The Ph Chromosome

Patients with ALL who have the Philadelphia chromosome have needed the most aggressive ALL therapy, but now there are treatments that specifically target the Philadelphia chromosome Adult ALL: Recent Key Breakthroughs

“Pediatric inspired” regimen in adolescent and young adults (AYA)

•Genomic alterations amenable to inhibition with approved tyrosine kinase inhibitors (TKIs) (Ph + and “Ph-like” ALL)

•Effective technologies to modify autologous T cells to target and kill B-ALL cells – Blinatumomab –CAR T cells

Treatment of Acute Leukemia and MDS MDS Natural History  With time disease can go in one of two directions • The bone marrow can make fewer and fewer normal cells resulting in more complications of low normal blood cells • The number of immature blood cells (blasts) can increase resulting in the development of acute leukemia which is hard to treat when it has come out of MDS  Course highly variable from patient to patient  Treatment depends on expected course IPSS Scoring System

 Based on outcomes for 816 untreated de novo MDS patients from large trials  Define patients with similar outcomes based on risk factors despite disparate morphology Patients stratified into 4 well-defined risk groups based on • Age • Cytogenetics • Number of low blood counts • % blasts

Silverman LR. The Oncologist. 2001;6(suppl 5)8-14. IPSS Risk Stratification Scores 0 0.5 1.0 1.5 2.0 BM Blast% <5 5-10 11-20 21-30

Karyotype Good Inter Poor nl,-y,5q-,20q- Complex,abnl 7 Cytopenias 0/1 2/3 hgb10,anc1800,plt 100

Risk Groups Low Int-1 Int-2 High IPSS 0 0.5-1.0 1.5-2.0 2.5-3.5

Adapted from Greenberg et al. Blood 1997 89:2079 5q- syndrome

 MDS where there is a missing portion of the long arm of chromosome 5  In these patients, profound anemia, but otherwise normal counts  Even without treatment very low risk of leukemia, but usually needs lots of red cell transfusions 5q- :Cytogenetics and FISH

del (5)(q13q33)

Vardiman JW. Available at: Heaney ML, Golde DW. http://www.ashimagebank.org/fullcase.asp?case_id=100197 N Engl J Med. 1999;340:1649 Lenalidomide

 Related to Thalidomide, which had been used to treat myeloma and MDS  More potent, fewer side effects  Initial studies showed responses in patients with low risk MDS and 10 of initial patients had abnormal chromosome 5 Lenalidomide in Transfusion-Dependent Patients With Low/Int-1 MDS (MDS-002/003)

Multicenter Phase II studies

R Eligibility R E E Yes Continue RBC transfusion ≥2 U/8 wk G Lenalidomide S 16 wk transfusion Hx I ANC >500/µL Dosing P Platelets >50,000/µL S 10 mg po × 21/28 d O T de novo MDS 10 mg po qd N Low/Int-1 MDS E S No Off Study MDS-003: del 5q31.1 R E MDS-002: other Dose Reduction 5 mg qd 5 mg qod Week: 0 6 12 18 24

Primary endpoint: transfusion independence (Hgb ↑ ≥1 g/dL) Secondary endpoints: cytogenetic response, pathologic response, safety

List A et al. N Engl J Med 2006;355:1456-1465 Del 5q: Lenalidomide Therapy in Transfusion Dependent Patients: Intent to Treat Erythroid Response at 24 wks (Preliminary Report)

Data Parameter Del 5q (n=148)

Erythroid response Transfusion indep 99 (67%)* Minor (>50% ↓) 13 (9%) Median duration of transfusion independence † >104 wks

Median Hgb rise 5.4 g/dL (1.1–11.4) Median time to initial response 4.6 wk (1–49)

*P<0.001; †not reached at median follow-up of 104 wk

No significant differences in erythroid response or TTR between 2 dosing regimens No differences in subgroup analysis 90% of responses occur within the first 3 months

List A et al. N Engl J Med 2006;355:1456-1465 Del 5q: Duration Transfusion Independence [n=99]

Median follow-up: 104 wks Median duration TI: 2.2 years Range: 8.6 – 89+ wks

List A et al. Proceedings ASH, 2006;abstract #251 Non Del 5q: Lenalidomide Therapy in Transfusion Dependent Patients: ITT Erythroid Response at 24 wks (Preliminary Report)

Data Parameter Non-del 5q (n=214)

Erythroid response Transfusion indep 56 (26%) Minor (>50% ↓) 36 (17%) Median duration of transfusion independence 41 wk

Median Hgb rise 3.2 g/dL (1.0–9.8) Median time to initial response 4.5 wk (2.7-6.7)

No significant differences in erythroid response or TTR between 2 dosing regimens 90% of responses occur within the first 3 months

List A et al. N Engl J Med 2006;355:1456-1465 List AF et al. Oral presentation at: 10th Congress of the EHA; June 2–5, 2005; Stockholm, Sweden MDS-002/003:

Lenalidomide promotes transfusion independence (TI) in low-risk, transfusion-dependent MDS patients Red cell response significantly greater in patients with del 5q Low blood counts common Manageable with treatment interruption and dose reduction

List A et al. N Engl J Med 2006;355:1456-1465 Raza A et al. Proceedings ASH Annual Meeting; 2006 Epigenetic agents

 Genes in the cells can be turned on and off  Normally some are on and some are turned off  In MDS cells, some genes that should be turned on have been turned off • Maturation • Tumor suppressor  Several different classes of drugs have been shown to turn back on genes that have been turned off • Hypomethylating agents • Histone deacetylaste inhibitors

Schmelz et al. Leukemia. 2005;19:103. Study 9221A Randomized Phase III Controlled Trial of Subcutaneous Azacitidine in Myelodysplastic Syndromes

No Continue until S R 1) Supportive Exit Endpoint + RA t a Care* Criteria + RARS r n Yes Aza C A a d (dose as per arm #2) Response RAEB o S t - Continue Rx RAEB-T m S i i 2) Aza C75mg/m2/d x 7 days q28 x 4 E No Response CMML f z S - Off Study y e S

M M M 0 29 57 113 Day * Minimum duration of supportive care = 4 months M = Bone Marrow Aza C – Azacitidine S.C. unless transform to AML; death or plts < 20 x 109/L at week 8 or later Silverman L. The Oncologist 2001. 6 (S5): 8-14. Silverman LR, et al. J Clin Oncol. May 2002;20(10):2429-2440. Kornblith AB, et al. J Clin Oncol 2002. 18:2427-39 Quality of Life Impact: EORTC Fatigue, Dyspnea & Physical Functioning of Crossover Patients on Supportive Care for 4 months Prior to Crossover (N=30)

80 70 Physical Function* 60 p = .018 50 Fatigue ** 40 p = .0031 EORTC 30 20 Dyspnea ** 10 p = .0003 0 0 107 250 Supportive Care Crossover AZA Time (days)

* Higher Scores = Better Functioning ** Lower Scores = Symptom Improvement Kornblith et al., Impact of Azacytidine on QOL of Patients with MDS Treated in a Randomized Phase III Trial: a CALGB StudyJ Clin Oncol 2002; 20: 2441-52. Reprinted with permission from the American Society of Clinical Oncology. Acute Leukemia Initial Studies Blood counts Blood tests to determine if the leukemia is causing other complications • Tumor lysis—waste products of the leukemia cells can clog the kidneys • DIC Look for infections Spinal taps Marrow aspirate/biopsy Acute Leukemia--Treatment Stages

 Remission Induction • Initial goal of treatment is complete remission – no evidence of leukemia – return of normal bone marrow and blood cells  Postremission Therapy • prevent relapse of disease  Salvage Therapy Toxicity

 Side effects • Low blood counts • Hair loss • Mucositis-stomatitis • Nausea and vomiting • Fatigue • Possible cardiotoxicity  Supportive Care essential  Newer less toxic regimens being developed for patients not candidates for standard therapy Induction Chemotherapy Drug therapy Destroys rapidly dividing cells Non specific • Kills off the leukemic cells • Also destroys normal blood cells, other rapidly dividing cells, i.e. hair, mucosa It can take more than one round of chemotherapy to get rid of all of the leukemia cells

Remission

 Bone marrow and blood counts normal  Once leukemia gone worry about it coming back  Post remission therapy • Chemotherapy that is similar to but less intensive than the initial chemotherapy • Bone marrow or stem cell transplantation • Maintenance –low dose long term chemotherapy Myeloablative transplantation Use of high doses of chemotherapy +/- radiation to kill the patients’ bone marrow followed by an “infusion of stem cells” from the blood or the bone marrow . Autologous stem cell transplant . Allogeneic stem cell transplant

Autologous Transplant

 Use of the patients own cells to repopulate the bone marrow  Requires healthy patient cells  Risk of relapse even if the cells look healthy  Research now focusing on things that can be done to decrease the chances that patient will relapse Allogeneic Transplant

 Use of someone else’s cells to repopulate the bone marrow—requires a “match”  Benefit of getting the donor’s immune system which may help fight the leukemia  Risk of complications related to having that immune system attack the patient’s normal cells—Graft vs. host disease.

Non-myeloablative AlloSCT

 Use of donor immune system  Patients receive lower dose chemotherapy or radiation followed by infusion of donor stem cells or lymphocytes  Aim for graft-vs-tumor effect without side effects of myeloablative chemotherapy  Encouraging results in MDS and AML mostly in patients not eligible for standard transplant but may be as good as standard for some

History of ALL Therapy

 1940’s: single agent chemotherapy  1950’s: combination chemotherapy  1960’s: maintenance chemotherapy, first group of children cured  1980’s: Induction followed by consolidation followed by reinduction and reconsolidation Survival in CCG ALL Trials

1968-1978 “Total Therapy” Addition of CNS Prophylaxis Number of to Systemic Chemotherapy Children

1972- 93 75 6 % Survival %

1968-70 402

0 2 4 6 8 10 Years after Study Entry Adult ALL

 Remission induction successful in >70% of patients  CNS prophylaxis is now standard  Studies in adults show that long term disease free survival ( i.e. no relapse) is most likely if a bone marrow transplant is done from a HLA identical sibling in first remission in younger patients • For adolescents and young adults, studies now looking at whether regimens used in children would be benificial and may avoid the need for transplant  For patients with the Philadelphia chromosome, risk of relapse is higher, so need to be very aggressive, if possible. • New drugs, Gleevec, which blocks the protein made by the Philadelphia chromosome currently being used.

AML Therapy  1962- -6MP/MTX able to induce temporary remission in few AML pts  1970's-- Ara-C developed  Ara-C ± 6TG or DNR---50%CR  1980's • 3+7 regimen--Anthracycline (DNR/ADR) + Ara-C --CR rate 65-80% • high dose Ara-C consolidation resulted in long term survival Randomized Trials—Conclusion

 Several studies have been done to look at each form of consolidation therapy in first remission AML • Allogeneic transplant • Autologous transplant • Chemotherapy alone  No clear winner  Patients who relapse after chemotherapy can often be salvaged by transplant  Trials not designed to determine if BMTmay be of benefit in certain populations • In young patients who have poor prognostic disease, allogeneic transplant is the treatment of choice if a donor is available • Otherwise chemotherapy or autologous transplant or Choosing Treatment Treatment choice based on • Disease stage – Newly diagnosed – In remission – Refractory to therapy – Relapsed • Disease characteristics – Chromosomes – Molecular markers • Patient characteristics – Age – Other diseases

Advances in leukemia therapy Ideal therapy would be one that is toxic to the leukemia cells but not to the normal cells

Acute Promyelocytic Leukemia

 M3 AML  Because of complications related to the disease, used to be the type of AML that was the most dangerous  Now with newer therapies, has become the most treatable AML APL and ATRA

 t(15;17) determined in the 1970’s • 1990’s it was determined that the 15;17 translocation resulted in an abnormal gene • This abnormal gene was found to affect the way the cells handled a chemical in the body called retinoic acid that allowed the cells to mature properly – In the presence of the abnormal gene the cells were not able to mature properly  Through a sequence of clinical trials it was determined that by simply giving a Vitamin A derivative, ATRA, in addition to chemotherapy , we are able to overcome the problem • More patients go into remission • More patients stay in remisson

APL is now one of the most curable forms of leukemia.

Tallman, M. S. et. al. N Engl J Med 1997;337:1021-1028 What’s new Using novel nontoxic agents with different mechanisms of action • Clinical trials Better medicines to manage side effects of the disease and its treatment Personalized diagnostics • Identifying genes and targets that are prognostic and allow for novel therapies

Mutation summary

Including cytogenetic abnormalities, 591 somatic mutations in 398 samples:

91% with clonal somatic abnormality

N % 0 35 9 1 167 42 2 145 36 3 45 8 4 6 1 Revised AML Risk Stratification Based on Integrated Mutational Profiling

Green and red curves represent patients whose risk-classification changes using more extensive mutational profiling Relevance to Clinical Practice

 E1900 tested standard dose vs. high dose daunorubicin in induction  Study demonstrated benefit to high dose in induction  Genetic factors influence effects of induction dose intensity  High dose Daunorubicin improves outcome in pts with DNMT3, MLL or NPM1 mutations

DNMT3A, MLL, or NPM1 mutant

__-_High Dose - - Standard dose P=0.001 Cooperative group trials

ALL • Use of pediatric regimens in adolescents &young adults • Therapy for Ph positive ALL incorporating TKI and transplant AML • Arsenic Trioxide , ATRA, Mylotarg induction for APL • Standard Dauno/Ara vs Clofarabine for elderly AML • Randomized trial of novel regimens for relapsed AML

Novel Therapeutics  AML/MDS • Sirolimus / MEC (Carroll/ Perl) • Bexarotene (Tsai) • Eltrombopag (Frey) • SMAC Mimetics (Frey/ Luger) • FLT 3 Inhibitors ( Perl) • Bromodomain Inhibitors ( Mangan/Luger) • Sapacitabine (Luger) • Onconova--PLK1/G2-M inhibitor (Luger)  ALL • Blinatumomab

Conclusions

 Treatment of acute leukemia and MDS results can lead to long term survival without disease  Clinical trials have allowed us to learn more about the different types of leukemia and to evaluate new therapeutic options and develop improved regimens  Newer therapies will hopefully further improve remission rates and decrease toxicities  Personalized diagnostics will enhance our ability to diagnose and choose the correct treatment.